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Nourishing networks: A social-ecological analysis of a network intervention for improving household nutrition in Western Kenya

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  • University of British Columbia
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Nourishing networks: A social-ecological analysis of a network intervention for improving household nutrition in Western Kenya

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... Mothers, fathers, grandmothers, and other family members typically reported positive experiences, improved nutrition behaviors, and enhanced relationships. Family members described changes in nutrition knowledge and practices (48-50, 52, 68, 78, 79) and appreciated learning about MIYCN recommendations (46,49,50). All studies found that family members reported providing emotional, informational, or instrumental support, and several reported mothers appreciated the increased support (46,49,53,54,61). ...
... Family members described changes in nutrition knowledge and practices (48-50, 52, 68, 78, 79) and appreciated learning about MIYCN recommendations (46,49,50). All studies found that family members reported providing emotional, informational, or instrumental support, and several reported mothers appreciated the increased support (46,49,53,54,61). Several studies reported that mothers, fathers, and grandmothers attributed improved communication and family relationships to their participation in the intervention (46, 48, 52-54, 68, 77-79), as well as improved social norms (46, 48, 49, 52-54, 68, 77). ...
... Findings from almost all of the qualitative studies, which used a variety of delivery approaches, suggest that interventions to engage family members were acceptable and feasible (46, 48-53, 64, 68, 74, 77-79), particularly when designing interventions that build on existing norms and family members' roles (46, 48-53, 64, 68, 74, 77-79) or use principles of participatory facilitation (46, 48-53, 64, 68, 74, 77-79). However, some challenges around engaging fathers were identified, such as when fathers did not participate in activities (50,64), received negative comments from others in the community about behaviors inconsistent with traditional gender norms (64), and experienced financial constraints limiting their ability to buy recommended foods (49,51). While most qualitative studies reviewed reported positive changes in relationships, 2 qualitative studies (53, 64) described 1 or 2 participants who reported that fathers became overbearing and pressured mothers to practice recommended behaviors. ...
Article
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Fathers, grandmothers, and other family members' influence on maternal, infant, and young child nutrition (MIYCN) is widely recognized, yet synthesis of the effectiveness of engaging them to improve nutrition practices during the first 1000 d is lacking. We examined the impact of behavioral interventions to engage family members in MIYCN in low- and middle-income countries through a mixed-methods systematic review. We screened 5733 abstracts and included 35 peer-reviewed articles on 25 studies (16 with quantitative and 13 with qualitative data). Most quantitative studies focused on early breastfeeding, primarily engaging fathers or, less often, grandmothers. Most found positive impacts on exclusive breastfeeding rates and family members' knowledge and support. The few quantitative studies on complementary feeding, maternal nutrition, and multiple outcomes also suggested benefits. Qualitative themes included improved nutrition behaviors, enhanced relationships, and challenges due to social norms. Interventions engaging family members can increase awareness and build support for MIYCN, but more rigorous study designs are needed. This systematic review is registered at PROSPERO as CRD42018090273, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=90273.
... Abbreviations: ANC, Antenatal care; BF, Breastfeeding; BRAC, an international development organization based in Bangladesh; EBF, Exclusive breastfeeding; C, children; CF, complementary feeding; CG, caregiver; CHW, community health workers and is used to denote village health worker, community resource person, community health volunteer; C-RCT, cluster randomized control trial; F, Fathers; FGD, focus group discussion; Gm, Grandmothers; IDI, In-depth Interview; IFA, Iron Folic Acid supplements; IYCF, infant and young child feeding; M, mothers; O, others; PMTCT, prevention of mother-to-child transmission; RCT, randomized control trial; WASH, water, sanitation, and hygiene; WRA, women of reproductive age. Gu et al., 2016;Rempel et al., 2017), two used the Theory of Reasoned Action (Hoddinott et al., 2018;Nguyen et al., 2018), two used Social Cognitive Theory (Rabiepoor et al., 2019;Singla et al., 2015), two used the socioecological model (DeLorme et al., 2018;Mukuria et al., 2016), two used theoretical concepts related to social support and social networks (Bootsri & Taneepanichskul, 2017;, one used the transtheoretical model (Salasibew et al., 2019), and one used the Beliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) model (Akbarzadeh et al., 2015). Four studies based intervention design on multiple theories and constructs Aubel, 2012;Hoddinott et al., 2018;H. ...
... At the community level, home visits were used by 19 studies to meet with individual mothers and family members and were conducted by community health workers (CHW) (DeLorme et al., 2018;Horii et al., 2016;Kumar et al., 2018;Nguyen et al., 2018;Selassie & Fantahun, 2011;Susiloretni et al., 2013Susiloretni et al., , 2015, peer counsellors (Haider & Thorley, 2019) and health care providers . Other family members were sometimes counselled together with mothers (Nunes et al., 2011) or encouraged to participate if they were available during the home visit for the mother . ...
... There were studies that formed new groups, while others built on existing groups and integrated nutrition content into ongoing activities. Group meetings were facilitated by Ministry of Health or NGO staff(Aubel et al., 2004), community health workers(DeLorme et al., 2018), village savings and loan association volunteer leaders ...
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The influence of fathers, grandmothers and other family members on maternal, infant and young child nutrition practices has been well documented for decades, yet many social and behavioural interventions continue to reach only mothers. While recent guidelines recommend involving fathers, grandmothers and other family members in maternal and child nutrition, we lack a comprehensive review of interventions that have engaged them. This scoping review aimed to address this gap by describing social and behavioural interventions to engage family members in maternal and child nutrition in low‐ and middle‐income countries. We systematically searched PubMed, Scopus, Web of Science, Global Health and CINAHL for peer‐reviewed studies meeting inclusion criteria. We screened 6,570 abstracts, evaluated 179 full‐text articles, and included 87 articles from 63 studies. Studies reported a broad range of approaches to engage fathers, grandmothers and other family members to support maternal nutrition (n = 6); breastfeeding (n = 32); complementary feeding (n = 6) and multiple maternal and child nutrition practices (n = 19). Interventions were facility and community based; included individual and group‐based interpersonal communication, community mobilization, mass media and mHealth; and reached mothers and family members together or separately. Most interventions were located within the health sector; rare exceptions included nutrition‐sensitive agriculture, social protection, early child development and community development interventions. Few interventions addressed gender norms, decision‐making, and family dynamics or described formative research or theories informing intervention design. These diverse studies can shed light on innovative programme approaches to increase family support for maternal and child nutrition.
... The programme aimed to engage social support networks, including fathers, grandparents, and other community members, and strengthen relationships with CHWs to drive sustainable behaviour changes. The objectives of the intervention were to improve IYCF practices and establish social network support for access to nutritious foods (DeLorme et al., 2018). ...
... qualitative evaluation of the Kanyakla Nutrition Program demonstrated improvements in programme participants' knowledge and confidence regarding nutrition behaviour and feeding young children (DeLorme et al., 2018). The programme also engaged male caregivers, and both male and female participants identified structural barriers to food access (e.g., income and limited access to irrigation) that prevented them from fully enacting their knowledge (DeLorme et al., 2018). ...
... qualitative evaluation of the Kanyakla Nutrition Program demonstrated improvements in programme participants' knowledge and confidence regarding nutrition behaviour and feeding young children (DeLorme et al., 2018). The programme also engaged male caregivers, and both male and female participants identified structural barriers to food access (e.g., income and limited access to irrigation) that prevented them from fully enacting their knowledge (DeLorme et al., 2018). Despite the inclusion of the social network component, the findings of this study are similar to studies evaluating maternal education programmes that improved maternal knowledge and attitudes towards appropriate feeding practices but did not significantly improve actual dietary diversity and meal frequency (Agbozo, Colecraft, & Ellahi, 2015;Christian et al., 2016;Gyampoh, Otoo, & Aryeetey, 2014 i Minimum acceptable diet criteria: For children who are currently breastfeeding, both minimum meal frequency and minimum dietary diversity criteria must be met; for children who are not currently breastfeeding, the minimum meal frequency criteria must be met and the child must receive two dairy servings and consume four out of the six non-dairy food groups described above (WHO, 2008). ...
Article
Food insecurity and poor infant and young child feeding (IYCF) practices contribute to undernutrition. The Kanyakla Nutrition Program was developed in rural Kenya to provide knowledge alongside social support for recommended IYCF practices. Utilizing a social network approach, the Kanyakla Nutrition Program trained Community Health Workers to engage mothers, fathers, and grandparents in nutrition education and discussions about strategies to provide instrumental, emotional, and information support within their community. The twelve‐week program included six sessions and was implemented on Mfangano Island, Kenya in 2014‐2015. We analyzed intervention effects on (1) nutrition knowledge among community members or CHWs, and (2) IYCF practices among children 1‐3 years. Nutrition knowledge was assessed using a post intervention comparison among intervention (community, n=43; CHW, n=22) and comparison groups (community, n=149; CHW, n=64). We used a quasi‐experimental design and difference‐in‐difference to assess IYCF indicators using dietary recall data from an on‐going cohort study among intervention participants (n=48) with individuals living on Mfangano Island where the intervention was not implemented (n=178) before the intervention, within one month post intervention, and six months post intervention. Findings showed no effect of the intervention on IYCF indicators (e.g., dietary diversity, meal frequency) and less than 15% of children met minimum acceptable diet criteria at any time point. However, knowledge and confidence among community members and CHWs was significantly higher two‐years post intervention. Thus, a social network approach had an enduring effect on nutrition knowledge, but no effects on improved IYCF practices.
... Community and religious leaders and, in some contexts, community health workers (CHWs), may enforce existing norms or encourage shifts in social norms through their influential roles and status. Nine interventions trained community or religious leaders or health workers to advocate, mobilize, and implement activities to influence CF behaviors and norms in communities (59, 60,[63][64][65][66][67][68][69][70][71][72][73][74][75][76]. For example, the Kanyakla Nutrition Program trained CHWs to facilitate community discussions and serve as community ambassadors promoting nutrition practices through modeling and informal conversations (63,69). ...
... Nine interventions trained community or religious leaders or health workers to advocate, mobilize, and implement activities to influence CF behaviors and norms in communities (59, 60,[63][64][65][66][67][68][69][70][71][72][73][74][75][76]. For example, the Kanyakla Nutrition Program trained CHWs to facilitate community discussions and serve as community ambassadors promoting nutrition practices through modeling and informal conversations (63,69). ...
... Five programs described barriers to achieving program impact in their qualitative findings (60,63,69,77,79,80), with 3 citing existing cultural norms or traditional beliefs (44,52,63). ...
Article
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The influence of social norms on child feeding is recognized, but guidance is lacking on how to address norms and related perceptions that hinder or support positive nutrition practices. We reviewed recent peer-reviewed and grey literature to summarize social norms relevant to complementary feeding (CF), intervention approaches that address norms, and their impacts on social norms and CF outcomes. Many reports described various norms, customs, and perceptions related to appropriate foods for young children, parenting practices, gender and family roles, but rarely explored how they motivated behavior. Community engagement and media interventions addressed norms through facilitated discussions, challenging negative norms, portraying positive norms, engaging emotions, and correcting misperceptions. Evaluations of norms-focused interventions reported improved CF practices, but few assessed impacts on social norms. Although multiple contextual factors influence CF practices, evidence suggests the feasibility and effectiveness of addressing social norms as one component of programs to improve CF practices.
... Quantitative intervention studies tend to focus on maternal reports of father support or fathers' knowledge and practices. Qualitative studies have reported on fathers' increased knowledge of complementary feeding (DeLorme et al., 2018;Downs et al., 2019), father involvement in decision making (Dinga et al., 2018), participatory methods to involve fathers in child care and perceptions of masculinity and willingness to change gender norms and roles around child care (Bezner Kerr, Chilanga, et al., 2016). However, less is known about fathers' reactions to complementary feeding recommendations or their experiences supporting or practicing these recommendations. ...
... Reaching mothers and fathers through home visits has been used elsewhere Salasibew et al., 2019). Other approaches to engage fathers in complementary feeding or maternal and child nutrition broadly, include counselling couples together at health facilities (Dinga et al., 2018), community-based fathers' groups (Mukuria et al., 2016), and support groups that bring family members together with other families DeLorme et al., 2018). ...
Article
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In Tanzania, suboptimal complementary feeding practices contribute to high stunting rates. Fathers influence complementary feeding practices, and effective strategies are needed to engage them. The objectives of this research were to examine the acceptability and feasibility of (1) tailored complementary feeding recommendations and (2) engaging fathers in complementary feeding. We conducted trials of improved practices with 50 mothers and 40 fathers with children 6-18 months. At visit 1, mothers reported current feeding practices and fathers participated in focus group discussions. At visit 2, mothers and fathers received individual, tailored counselling and chose new practices to try. After 2 weeks, at visit 3, parents were interviewed individually about their experiences. Interview transcripts were analysed thematically. The most frequent feeding issues at visit 1 were the need to thicken porridge, increase dietary diversity, replace sugary snacks and drinks and feed responsively. After counselling, most mothers agreed to try practices to improve diets and fathers agreed to provide informational and instrumental support for complementary feeding, but few agreed to try feeding the child. At follow-up, mothers reported improved child feeding and confirmed fathers' reports of increased involvement. Most fathers purchased or provided funds for recommended foods; some helped with domestic tasks or fed children. Many participants reported improved spousal communication and cooperation. Families were able to practice recommendations to feed family foods, but high food costs and seasonal unavailability were challenges. It was feasible and acceptable to engage fathers in complementary feeding, but additional strategies are needed to address economic and environmental barriers.
... one identified need is ensuring sufficient master trainers are available to meet the demand, alongside training and social and behaviour change counselling materials, to build nutrition competencies of health providers(De Lorme et al., 2018;Wainaina, Wanjohi, Wekesah, Woolhead, & Kimani-Murage, 2018).In addition, although BFCI has experienced much success, key challenges remain for tracking implementation within the Kenya health information system. Regarding BFCI routine monitoring data, social desirability bias may be an issue. ...
Article
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The Baby‐Friendly Community Initiative (BFCI) is an extension of the 10th step of the Ten Steps of Successful Breastfeeding and the Baby‐Friendly Hospital Initiative (BFHI) and provides continued breastfeeding support to communities upon facility discharge after birth. BFCI creates a comprehensive support system at the community level through the establishment of mother‐to‐mother and community support groups to improve breastfeeding. The Government of Kenya has prioritized community‐based programming in the country, including the development of the first national BFCI guidelines, which inform national and subnational level implementation. This paper describes the process of BFCI implementation within the Kenyan health system, as well as successes, challenges, and opportunities for integration of BFCI into health and other sectors. In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 support groups established, and 3,065 children 0–12 months of age reached (MCSP only). Though difficult to attribute to our programme, improvements in infant and young child feeding practices were observed from routine health data following the programme, with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and (37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation and exclusive breastfeeding in Migori were also noted—from 85.9% to 89.3% and 75.2% to 92.3%, respectively. Large gains in consumption of iron‐rich complementary foods were also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduction of complementary foods (42.0–83.3% in Migori). Coverage for BFCI activities varied across counties, from 20% to 60% throughout programme implementation and were largely sustained 3 months postimplementation in Migori, whereas coverage declined in Kisumu. BFCI is a promising platform to integrate into other sectors, such as early child development, agriculture, and water, sanitation, and hygiene.
... Adherence partners were motivated to support adherence because they believed supplementation was important for women's health in pregnancy, and providing adherence support was consistent with how many husbands and other family members perceived their role. Other maternal and child nutrition studies in Kenya have found that family members want nutrition information, and are willing to support maternal and child nutrition practices (25)(26)(27). ...
Article
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Background In countries with low calcium intake, the WHO recommends integrating calcium supplementation into antenatal care (ANC) to reduce the risk of preeclampsia, a leading cause of maternal mortality. Current WHO guidelines recommend women take 3–4 calcium supplements plus 1 iron-folic acid supplement at separate times daily. There is limited evidence about implementing these guidelines through routine ANC. Through the Micronutrient Initiative-Cornell University Calcium (MICa) trial, we examined the effect of regimen on supplement consumption among ANC clients in western Kenya. A nested process evaluation examined factors that influence calcium supplementation delivery and uptake. Objectives This process evaluation assessed ANC providers’, pregnant women's, and family members’ experiences with calcium supplementation, and investigated the feasibility and acceptability of engaging family members to support adherence. Methods We conducted semistructured interviews with 7 ANC providers, 32 pregnant women, and 20 adherence partners (family members who provide reminders and support), and 200 observations of ANC consultations. Interviews were transcribed, translated, and analyzed thematically. Observational data were summarized. Results ANC providers reported positive feelings about calcium supplementation, the training received, and counseling materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, offered reminder strategies, and provided supplements and behavior change materials. Women explained that reminder materials and adherence partners improved adherence. Most adherence partners reported providing reminders and other instrumental support to help with pill taking, which women confirmed and appreciated. Some women reported that comorbidities, concerns about being perceived as HIV positive, pill burden, unfavorable organoleptic properties, and lack of food were adherence barriers. Conclusions Although integrating calcium into antenatal iron-folic acid supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be considered to successfully implement these guidelines. This trial was registered at clinicaltrials.gov as NCT02238704.
... [25][26][27][28] At the same time, an approach centering on mothers can drive feelings of frustration, alienation and even helplessness among fathers and others who support mothers. [29][30][31][32] Further, a tendency to zero-in on individual parentsto-be may pull policy attention away from some of the larger structures (e.g. those involved in employment, in wealth distribution, and in food production and distribution) [33][34][35] well-situated to improve children's early life environmental conditions. ...
Article
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Evidence supporting the Developmental Origins of Health and Disease (DOHaD) hypothesis indicates that improving early life environments can reduce non-communicable disease risks and improve health over the lifecourse. A widespread understanding of this evidence may help to reshape structures, guidelines and individual behaviors to better the developmental conditions for the next generations. Yet, few efforts have yet been made to translate the DOHaD concept beyond the research community. To understand why, and to identify priorities for DOHaD Knowledge Translation (KT) programs, we review here a portion of published descriptions of DOHaD KT efforts and critiques thereof. We focus on KT targeting people equipped to apply DOHaD knowledge to their everyday home or work lives. We identified 17 reports of direct-to-public DOHaD KT that met our inclusion criteria. Relevant KT programs have been or are being initiated in nine countries, most focusing on secondary school students or care-workers-in-training; few target parents-to-be. Early indicators suggest that such programs can empower participants. Main critiques of DOHaD KT suggest it may overburden mothers with responsibility for children's health and health environments, minimizing the roles of other people and institutions. Simultaneously, though, many mothers-to-be seek reliable guidance on prenatal health and nutrition, and would likely benefit from engagement with DOHaD KT. We thus recommend emphasizing solidarity, and bringing together people likely to one day become parents (youth), people planning pregnancies, expecting couples, care workers and policymakers into empowering conversation about DOHaD and about the importance and complexity of early life environments.
... Although research has shown that fathers are key influencers of IYCF practices, a recent review found that most studies targeting fathers in LMICs have focused on their role in supporting breastfeeding (20). Only a handful of studies included interventions that encouraged fathers to be more involved in their children's complementary feeding and most of these did not quantitatively measure intervention effects (22,(29)(30)(31)(32). The present study in Igabi LGA, Kaduna State, Nigeria, engaged fathers in supporting complementary feeding through interpersonal communication, community mobilization, mass media, and mobile phone messaging, and provided information and advice to mothers mainly through interpersonal communication during home visits and mass media. ...
Article
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Background Fathers are key influencers of complementary feeding practices, but few studies in low- and middle-income countries have measured the effects of complementary feeding social and behavior change communication (SBCC) targeted at both fathers and mothers. Objective To measure the effects of an SBCC intervention on children's dietary diversity (primary outcome) and other complementary feeding indicators, fathers’ and mothers’ complementary feeding knowledge, and fathers’ support for complementary feeding (secondary outcomes). Methods The 12-month intervention in Kaduna State, Nigeria engaged parents through community meetings, religious services, home visits from community health extension workers (CHEWs), mobile phone messages (fathers only), and mass media. Cross-sectional population-based surveys of cohabiting fathers and mothers with a child 6-23 months were conducted, and regression models were used to compare results at baseline (N = 497) and endline (N = 495). Results Children's minimum dietary diversity did not change from baseline to endline (62% to 65%, P = 0.441). Consumption of fish (36% to 44%, P = 0.012) and eggs (8% to 20%, P = 0.004) and minimum meal frequency (58% to 73%, P<0.001) increased. Fathers’ and mothers’ knowledge of the timing of introduction of different foods and meal frequency improved. Fathers’ support for child feeding by providing money for food increased (79% to 90%, P<0.001). Fathers’ and mothers’ reported intervention exposure was low (11%-26% across types of SBCC). Child feeding outcomes were not associated with fathers’ exposure, but odds of both fish and egg consumption increased significantly with mothers’ exposure to community meetings, religious services, home visits, and TV spots and odds of minimum meal frequency increased significantly with mothers’ exposure to home visits. Conclusions A multipronged SBCC intervention improved complementary feeding practices, fathers’ and mothers’ knowledge of complementary feeding, and fathers’ support for complementary feeding, despite low levels of reported exposure, which may have been influenced by COVID-19 disruptions. Registered with ClinicalTrials.gov (NCT04835662).
... Therefore, nutrition messages can be directed toward fathers and lead to a positive health impact (48,49). The course of actions for engaging fathers to improve the infant and young child feeding practices can be designed to be embedded in their social networks, which has shown positive results in Kenya (50)(51)(52)(53). Similarly, to boost the momentum of nutrition actions of food-insecure Ethiopia households, the child feeding message can be disseminated via a platform of men groups in their cultural settings. ...
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Background: Ethiopia is affected by recurrent drought and food insecurity crises including from El Niño, the climatic change that lasted from mid-2014 through 2016 and caused the failure of the rainy seasons in eastern Ethiopia. The event is expected to have a detrimental effect on the already suboptimal complementary feeding practices. However, there is a lack of research on how climatic events affect child feeding. Hence, the study was intended to explore how El Niño influenced the complementary feeding practices and experiences of the food-insecure community of eastern Ethiopia from March to September 2016. Methods: This study was an exploratory qualitative study that used a phenomenological approach. The study was conducted in the food-insecure setting of Gale Mirga kebele of Kersa district. The study involved 11 focus group discussion (FGD) comprising a total of 76 participants, including three FGDs with mothers, three FGDs with Health Development Army leaders (HDA); two FGDs with fathers, two FGDs with traditional birth attendants, and one FGD with religious leaders. The Atlas.ti software was used for coding and thematic analysis. Results: El Niño aggravated failed crop and livestock loss were reported to directly reduce the quantity and quality of food available to feed young children, resulting in more frequent skipping of meals, less animal protein sources and over-reliance of cereal-based food. The impact of El Nino on livelihoods often resulted in both parents working away from home with child feeding delegated to older children or other family members. Maternal absence from home was a barrier to participation in community-based nutrition activities. Short birth spacing and low fathers’ involvement in feeding also reduced the time available to mothers to devote to child feeding. Conclusions: The maternal suboptimal time allocation to child feeding is central to the poor complementary feeding practices in El Niño stricken food-insecure settings of Eastern Ethiopia. The women should be supported with climate-resilient livelihoods options in their villages, thus allowing them both to feed their children and attend nutrition education sessions with HDA. Such sessions should focus on food processing demonstrations to improve the nutritional quality of plant-based complementary foods.
... P10 and her family had just moved to a new town in order to purchase an affordable home and had not formed relationships with her new neighbors. These findings are congruent with the recommendations of creating a strong social safety net and social networks among extended family in order to care for the nutritional needs of children and reduce the risk of material hardship (DeLorme et al., 2017;King, 2016;). Such social supports and networks can provide assistance when needs arise and would be beneficial for all who face food insecurity. ...
Article
Using the social-ecological model, this basic interpretive qualitative study sought to examine the phenomenon of food insecurity among Idaho Head Start enrolled families, focusing on barriers and deterrents to accessing available nutrition assistance programs. A total of 11 interviews were conducted with parents who had children enrolled in five Idaho Head Start programs. The data were coded and analyzed and are reflective of how individual, interpersonal, community, and organizational levels factors are reflected in participants’ decisions to access available nutrition assistance programs. Participants reported feelings of stigma and shame and transportation concerns as individual barriers as well as the interpersonal barrier of a lack of support systems. Lack of awareness of resources, limited food choices, and the questionable quality of foods provided at pantries were noted among the community and organizational deterrents. The results of this study may be used to create interventions that promote food security among Head Start families.
... Illustratively, in some contexts, acculturation [84] and immigration [87] are important shaping factors on youth/adolescent mental health, in other contexts these are not relevant. From geographic and cultural contexts as far ranging as rural northwest China [86], Romania [107], Latino youth in the United States [84], South Africa [78], South Korea [102], Kenya [42], Spain [87], African American [57], and Uganda [69] complex and dynamic relationships between various aspects of the child and family environment were characterized in diverse ways. The conceptual frameworks that were developed were influenced by geographic and cultural contexts. ...
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Background The family is a key setting for health promotion. Contemporary health promoting family models can establish scaffolds for shaping health behaviors and can be useful tools for education and health promotion. Objectives The objective of this scoping review is to provide details as to how conceptual and theoretical models of the health promoting potential of the family are being used in health promotion contexts. Design Guided by PRISMA ScR guidelines, we used a three-step search strategy to find relevant papers. This included key-word searching electronic databases (Medline, PSycINFO, Embase, and CINAHL), searching the reference lists of included studies, and intentionally searching for grey literature (in textbooks, dissertations, thesis manuscripts and reports.) Results After applying inclusion and exclusion criteria, the overall search generated 113 included manuscripts/chapters with 118 unique models. Through our analysis of these models, three main themes were apparent: 1) ecological factors are central components to most models or conceptual frameworks; 2) models were attentive to cultural and other diversities, allowing room for a wide range of differences across family types, and for different and ever-expanding social norms and roles; and 3) the role of the child as a passive recipient of their health journey rather than as an active agent in promoting their own family health was highlighted as an important gap in many of the identified models. Conclusions This review contributes a synthesis of contemporary literature in this area and supports the priority of ecological frameworks and diversity of family contexts. It encourages researchers, practitioners and family stakeholders to recognize the value of the child as an active agent in shaping the health promoting potential of their family context.
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Objective We wanted to identify factors related to dietary behavioural change among impoverished pregnant women in the face of nutrition education and counselling, describing what creates an enabling environment and barriers for dietary change. Design We used qualitative data from a cluster-randomised maternal education trial and conducted a thematic analysis using a social ecological framework to describe the factors that influenced dietary adherence. Setting Mangochi district in rural Malawi. Participants We interviewed ten pregnant women and conducted four sets of focus group discussions with twenty-two significant family members (husbands and mothers-in-law) and twelve counsellors. Results The participants’ experiences showed that the main barriers of adherence to the intervention were taste, affordability and poverty. The use of powders and one-pot dishes, inclusion of both women and significant family members and a harmonisation with local food practices enabled adherence to the intervention. We found it crucial to focus the dietary education and counselling intervention on locally available ingredients and food processing methods. Conclusions Use of contextualised food-based solutions to combat maternal malnutrition was observed to be relatively cheap and sustainable. However, there is need for more research on local foods used as nutrition supplements. We suggest that investments need to be directed not only to nutrition education and counselling but also to the enabling factors that enhance adherence. The original cluster-randomised controlled trial was registered with Clinical trials.gov ID: NCT03136393.
Article
There is abundant knowledge on the major health and social benefits of breastfeeding, and on how to protect, promote, and support breastfeeding. Hence, it is surprising that recommended breastfeeding behaviors continue to be suboptimal in the 21st Century among large segments of the population, globally. Moving forward, it is crucial to enable the breastfeeding environments for women through family friendly employment policies and to enforce the WHO Code for Marketing of Breastmilk Substitutes. It is also key to invest more in training the workforce for successful large-scale implementation and sustainability of the Baby Friendly Hospital Initiative, community-based breastfeeding counseling, and to prevent conflicts of interests with infant formula companies. Behavior change social marketing interventions that include social media need to be designed following social network science and behavioral economics principles. Evidence-informed policy tools are now available to help policy makers invest in and guide the scaling-up of cost-effective breastfeeding programs.
Article
As global health researchers, we have long embraced the conviction that the answers to complex problems of poverty and disease will reveal themselves if only we apply enough scientific rigor. Yet, at the community level, our group of American and Kenyan investigators has begun to question whether our veneration of rigor is itself contributing to the intractability of certain types of global health problems. Here, we illustrate examples from our experience among the remote island communities of Lake Victoria, Kenya, and join a chorus of emerging voices, to examine how our culture of control as global health scientists may marginalise truth-seekers and change-makers within communities we seek to serve. More broadly, we seek to acknowledge the limitations of control over truth that rigorous academic research affords. We suggest that by relinquishing this pervasive illusion of control, we can more fully appreciate complementary modes of answering important questions that rely upon the intrinsic resourcefulness and creativity of community-based enterprises taking place across sub-Saharan Africa. While such inquiries may never solve all problems facing the diverse populations of the continent, we advocate for a deeper appreciation of the inherent capacity of adaptive, locally contextualised investigations to identify meaningful and enduring solutions.
Chapter
Diet and nutrition are central to the wellbeing of communities, influencing the energy community members have to participate in the life of the community and the health outcomes of its members. Yet, community-level approaches to promoting nutritional health are inconsistent and vary across the world. This chapter proposes sustainable approaches to promote the nutritional health of communities based on the Social-Ecological Models and Policy Diffusion Models. We aim to describe nutrition and diet-related disparities in both the US and globally, discuss approaches that have been used to address these disparities, and finally, to outline potential strategies for building communities with sustainable food and nutrition plans that minimize disparities. We consider nutrition and diet-related disparities, hunger, and food insecurity in the US and across the world. We describe approaches that have been tried so far, including traditional interventions such as food distribution programs and education programs, as well as more recent approaches such as microloans and urban forests. We also discuss how cultural and political influences may influence diet-related disparity, such as how culturally preferred foods may affect efforts to improve diet quality and how political views of poverty may influence the types of policies considered acceptable to improve food access. Finally, we discuss areas that require continued research to improve communities’ nutritional health, such as improved mapping of nutrition problems and their barriers, how to implement more sustainable diets and food systems while respecting cultural foodways, and how to influence attitudes toward chronic poverty to expand the types of interventions available to policymakers.
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Objective Parents may rely on information provided by extended family members when making decisions concerning the health of their children. We evaluate whether extended family members affected the success of an information intervention promoting infant health. Methods This is a secondary, sequential mixed-methods study based on a cluster randomised controlled trial of a peer-led home-education intervention conducted in Mchinji District, Malawi. We used linear multivariate regression to test whether the intervention impact on child height-for-age z-scores (HAZ) was influenced by extended family members. 12 of 24 clusters were assigned to the intervention, in which all pregnant women and new mothers were eligible to receive 5 home visits from a trained peer counsellor to discuss infant care and nutrition. We conducted focus group discussions with mothers, grandmothers and peer counsellors, and key-informant interviews with husbands, chiefs and community health workers to better understand the roles of extended family members in infant feeding. Results Exposure to the intervention increased child HAZ scores by 0.296 SD (95% CI 0.116 to 0.484). However, this effect is smaller in the presence of paternal grandmothers. Compared with an effect size of 0.441 to 0.467 SD (95% CI −0.344 to 1.050) if neither grandmother is alive, the effect size was 0.235 (95% CI −0.493 to 0.039) to 0.253 (95% CI −0.529 to 0.029) SD lower if the paternal grandmother was alive. There was no evidence of an effect of parents’ siblings. Maternal grandmothers did not affect intervention impact, but were associated with a lower HAZ score in the control group. Qualitative analysis suggested that grandmothers, who act as secondary caregivers and provide resources for infants, were slower to dismiss traditionally held practices and adopt intervention messages. Conclusion The results indicate that the intervention impacts are diminished by paternal grandmothers. Intervention success could be increased by integrating senior women.
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Understanding feedbacks between human and environmental health is critical for the millions who cope with recurrent illness and rely directly on natural resources for sustenance. Although studies have examined how environmental degradation exacerbates infectious disease, the effects of human health on our use of the environment remains unexplored. Human illness is often tacitly assumed to reduce human impacts on the environment. By this logic, ill people reduce the time and effort that they put into extractive livelihoods and, thereby, their impact on natural resources. We followed 303 households living on Lake Victoria, Kenya over four time points to examine how illness influenced fishing. Using fixed effect conditional logit models to control for individual-level and time-invariant factors, we analyzed the effect of illness on fishing effort and methods. Illness among individuals who listed fishing as their primary occupation affected their participation in fishing. However, among active fishers, we fou
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Background: We designed and tested an intervention that used dialogue-based groups to engage infants' fathers and grandmothers to support optimal infant feeding practices. The study's aim was to test the effectiveness of increased social support by key household influencers on improving mothers' complementary feeding practices. Methods: Using a quasi-experimental design, we enrolled mothers, fathers, and grandmothers from households with infants 6-9 months old in 3 rural communities (1 intervention arm with fathers, 1 intervention arm with grandmothers, and 1 comparison arm) in western Kenya. We engaged 79 grandmothers and 85 fathers in separate dialogue groups for 6 months from January to July 2012. They received information on health and nutrition and were encouraged to provide social support to mothers (defined as specific physical actions in the past 2 weeks or material support actions in the past month). We conducted a baseline household survey in December 2011 in the 3 communities and returned to the same households in July 2012 for an endline survey. We used a difference-in-difference (DiD) approach and logistic regression to evaluate the intervention. Results: We surveyed 554 people at baseline (258 mothers, 165 grandmothers, and 131 fathers) and 509 participants at endline. The percentage of mothers who reported receiving 5 or more social support actions (of a possible 12) ranged from 58% to 66% at baseline in the 3 groups. By endline, the percentage had increased by 25.8 percentage points (P=.002) and 32.7 percentage points (P=.001) more in the father and the grandmother intervention group, respectively, than in the comparison group. As the number of social support actions increased in the 3 groups, the likelihood of a mother reporting that she had fed her infant the minimum number of meals in the past 24 hours also increased between baseline and endline (odds ratio [OR], 1.14; confidence interval [CI], 1.00 to 1.30; P=.047). When taking into account the interaction effects of intervention area and increasing social support over time, we found a significant association in the grandmother intervention area on dietary diversity (OR, 1.19; CI, 1.01 to 1.40; P=.04). No significant effects were found on minimum acceptable diet. Conclusion: Engaging fathers and grandmothers of infants to improve their knowledge of optimal infant feeding practices and to encourage provision of social support to mothers could help improve some feeding practices. Future studies should engage all key household influencers in a family-centered approach to practice and support infant feeding recommendations.
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Background: We designed and tested an intervention that used dialogue-based groups to engage infants’ fathers and grandmothers to support optimal infant feeding practices. The study’s aim was to test the effectiveness of increased social support by key household influencers on improving mothers’ complementary feeding practices. Methods: Using a quasi-experimental design, we enrolled mothers, fathers, and grandmothers from households with infants 6–9 months old in 3 rural communities (1 intervention arm with fathers, 1 intervention arm with grandmothers, and 1 comparison arm) in western Kenya. We engaged 79 grandmothers and 85 fathers in separate dialogue groups for 6 months from January to July 2012. They received information on health and nutrition and were encouraged to provide social support to mothers (defined as specific physical actions in the past 2 weeks or material support actions in the past month).We conducted a baseline household survey in December 2011 in the 3 communities and returned to the same households in July 2012 for an endline survey. We used a difference-in-difference (DiD) approach and logistic regression to evaluate the intervention. Results: We surveyed 554 people at baseline (258 mothers, 165 grandmothers, and 131 fathers) and 509 participants at endline. The percentage of mothers who reported receiving 5 or more social support actions (of a possible 12) ranged from 58% to 66% at baseline in the 3 groups. By endline, the percentage had increased by 25.8 percentage points (P=.002) and 32.7 percentage points (P=.001) more in the father and the grandmother intervention group, respectively, than in the comparison group. As the number of social support actions increased in the 3 groups, the likelihood of a mother reporting that she had fed her infant the minimum number of meals in the past 24 hours also increased between baseline and endline (odds ratio [OR], 1.14; confidence interval [CI], 1.00 to 1.30; P=.047). When taking into account the interaction effects of intervention area and increasing social support over time, we found a significant association in the grandmother intervention area on dietary diversity (OR, 1.19; CI, 1.01 to 1.40; P=.04). No significant effects were found on minimum acceptable diet. Conclusion: Engaging fathers and grandmothers of infants to improve their knowledge of optimal infant feeding practices and to encourage provision of social support to mothers could help improve some feeding practices. Future studies should engage all key household influencers in a family-centered approach to practice and support infant feeding recommendations.
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The objective of this study was to investigate the relationship among socioeconomic status, social support, and food insecurity in a rural Kenyan island community. A cross-sectional random sample of 111 female heads of households representing 583 household members were surveyed in Mfangano Island, Kenya from August to October 2010 using adaptations of the Household Food Insecurity Access Scale and the Medical Outcomes Study Social Support Survey. In multiple linear regression models, less instrumental social support, defined as concrete direct ways people help others (B = -0.81; 95% confidence interval [CI] -1.45 to -0.17), and decreased ownership scale based on owning material assets (B = -2.93; 95% CI -4.99 to -0.86) were significantly associated with increased food insecurity, controlling for age, education, marital status, and household size. Social support interventions geared at group capacity and resilience may be crucial adjuncts to improve and maintain the long term food security and health of persons living in low-resource regions.
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Food-producing livelihoods have the potential to improve food security and nutrition through direct consumption or indirectly through income. To better understand these pathways, we examined if fishing households ate more fish and had higher food security than non-fishing households around Lake Victoria, Kenya. In 2010, we randomly sampled 111 households containing 583 individuals for a cross-sectional household survey in a rural fishing community. We modeled the associations between fish consumption and food security and fishing household status, as well as socio-economic variables (asset index, monthly income, household size) for all households and also for a subset of households with adult male household members (76 % of households). Participating in fishing as a livelihood was not associated with household fish consumption or food security. Higher household fish consumption was associated with higher household income and food security, and was weakly associated with lower household morbidity. Household food security was associated with higher incomes and asset index scores. Our results suggest socioeconomic factors may be more important than participation in food-producing livelihoods for predicting household consumption of high quality foods.
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Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition and a growing problem with overweight and obesity. Low body-mass index, indicative of maternal undernutrition, has declined somewhat in the past two decades but continues to be prevalent in Asia and Africa. Prevalence of maternal overweight has had a steady increase since 1980 and exceeds that of underweight in all regions. Prevalence of stunting of linear growth of children younger than 5 years has decreased during the past two decades, but is higher in south Asia and sub-Saharan Africa than elsewhere and globally affected at least 165 million children in 2011; wasting affected at least 52 million children. Deficiencies of vitamin A and zinc result in deaths; deficiencies of iodine and iron, together with stunting, can contribute to children not reaching their developmental potential. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and, for survivors, of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. We estimate that undernutrition in the aggregate-including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc along with suboptimum breastfeeding-is a cause of 3·1 million child deaths annually or 45% of all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidity and infant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity, diabetes, and non-communicable diseases. The high present and future disease burden caused by malnutrition in women of reproductive age, pregnancy, and children in the first 2 years of life should lead to interventions focused on these groups.
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To determine the extent of exclusive breastfeeding practices among mothers of 4 and 6 month old infants whose fathers received breastfeeding education materials and counseling services. A quasi-experimental design was used. At the baseline, 251 and 241 couples were recruited into the intervention and control sites respectively. Fathers in the intervention area received breastfeeding education materials, counseling services at commune health centers and household visits. In the control site, where mothers routinely receive services on antenatal and postpartum care, fathers did not receive any intervention services on promoting breastfeeding. Primary indicators were exclusive breastfeeding at 4 and 6 months. At 6 months of age, based on 24-hour recall, 16.0 % (38/238) of mothers in the intervention group were exclusively breastfeeding their children, compared to 3.9 % (10/230) of those mothers in the control group (p < 0.001). Significant differences were found based on last-week recall (8.8 % in the intervention group vs. 1.3 % in the control group, p < 0.001) and since-birth recall (6.7 % in the intervention group vs. 0.9 % in the control group, p < 0.01). At 4 months of age, based on since birth recall, the breastfeeding proportion was significantly higher in the intervention group than in control group (20.6 % in the intervention group vs. 11.3 % in the control group, p < 0.01). An intervention targeting fathers might be effective in increasing exclusive breastfeeding practices at 4 and 6 months. To improve exclusive breastfeeding, health care staff working in maternal and child health units, should consider integrating fathers with services delivered to mothers and children.
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Informal sources of support, particularly the male partner, have more influence on breastfeeding behaviors than formal support from health care providers. This systematic review examined the impact of male-partner-focused breastfeeding interventions on breastfeeding initiation, exclusivity, and continuation. Four unique interventions were identified that were tested through randomized controlled studies or quasi-experimental design. These 4 provided breastfeeding education to fathers, with breastfeeding outcomes reported by the mother. Three of the 4 studies compared initiation rates between intervention and control conditions, and 2 showed significantly higher rates of breastfeeding initiation in the intervention group. Although studies were inconsistent in their categorization and reporting of full, partial, or no breastfeeding, significantly higher rates of breastfeeding initiation, exclusivity, and/or continuation were seen for 2 interventions. Because all 4 interventions found at least 1 breastfeeding outcome to be superior in the treatment group, breastfeeding education should be offered to male partners. Future studies should test if intervention effectiveness can be increased if education is supplemented with other activities. Future studies also should use controlled designs and validated outcome measures.
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Background: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. Methods: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. Findings: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. Conclusions: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. Funding: Bill & Melinda Gates Foundation.
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Fishing communities are often among the highest-risk groups in countries with high overall rates of HIV/AIDS prevalence. Vulnerability to HIV/AIDS stems from complex, interacting causes that may include the mobility of many fisherfolk, the time fishermen spend away from home, their access to daily cash income in an overall context of poverty and vulnerability, their demographic profile, the ready availability of commercial sex in fishing ports and the subcultures of risk taking and hypermasculinity among some fishermen. The subordinate economic and social position of women in many fishing communities in low-income countries makes them even more vulnerable. HIV/AIDS in fishing communities was first dealt with as a public health issue, and most projects were conducted by health sector agencies and NGOs, focusing on education and health care provision. More recently, as the social and economic impacts of the epidemic have become evident, wider social service provision and economic support have been added. In the last 3 years, many major fishery development programmes in Africa, South/South-East Asia and the Asia-Pacific region have incorporated HIV/AIDS awareness in their planning. The HIV/AIDS pandemic threatens the sustainability of fisheries by eclipsing the futures of many fisherfolk. The burden of illness puts additional stresses on households, preventing them from accumulating assets derived from fishing income. Premature death robs fishing communities of the knowledge gained by experience and reduces incentives for longer-term and inter-generational stewardship of resources. Recent projects championing local knowledge and resource-user participation in management need to take these realities into account. If the fishing communities of developing countries that account for 95% of the world's fisherfolk and supply more than half the world's fish are adversely impacted by HIV/AIDS, then the global supply of fish, particularly to lower-income consumers, may be jeopardized.
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Improving the nutritional status of infants and young children in developing countries depends to a significant extent on adoption of optimal nutrition-related practices within the context of the household. Most policies, research and programmes on child nutrition in non-Western societies focus narrowly on the mother-child dyad and fail to consider the wider household and community environments in which other actors, hierarchical patterns of authority and informal communication networks operate and influence such practices. In particular, the role and influence of senior women, or grandmothers, has received limited attention. Research dealing with child nutrition from numerous socio-cultural settings in Africa, Asia and Latin America reveals three common patterns related to the social dynamics and decision-making within households and communities. First, grandmothers play a central role as advisers to younger women and as caregivers of both women and children on nutrition and health issues. Second, grandmother social networks exercise collective influence on maternal and child nutrition-related practices, specifically regarding pregnancy, feeding and care of infants, young children and sick children. Third, men play a relatively limited role in day-to-day child nutrition within family systems. The research reviewed supports the need to re-conceptualize the parameters considered in nutritional policies and programmes by expanding the focus beyond the mother-child dyad to include grandmothers given their role as culturally designated advisers and caregivers.
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Childhood undernutrition is prevalent in low and middle income countries. It is an important indirect cause of child mortality in these countries. According to an estimate, stunting (height for age Z score < -2) and wasting (weight for height Z score < -2) along with intrauterine growth restriction are responsible for about 2.1 million deaths worldwide in children < 5 years of age. This comprises 21 % of all deaths in this age group worldwide. The incidence of stunting is the highest in the first two years of life especially after six months of life when exclusive breastfeeding alone cannot fulfill the energy needs of a rapidly growing child. Complementary feeding for an infant refers to timely introduction of safe and nutritional foods in addition to breast-feeding (BF) i.e. clean and nutritionally rich additional foods introduced at about six months of infant age. Complementary feeding strategies encompass a wide variety of interventions designed to improve not only the quality and quantity of these foods but also improve the feeding behaviors. In this review, we evaluated the effectiveness of two most commonly applied strategies of complementary feeding i.e. timely provision of appropriate complementary foods (± nutritional counseling) and education to mothers about practices of complementary feeding on growth. Recommendations have been made for input to the Lives Saved Tool (LiST) model by following standardized guidelines developed by Child Health Epidemiology Reference Group (CHERG). We conducted a systematic review of published randomized and quasi-randomized trials on PubMed, Cochrane Library and WHO regional databases. The included studies were abstracted and graded according to study design, limitations, intervention details and outcome effects. The primary outcomes were change in weight and height during the study period among children 6-24 months of age. We hypothesized that provision of complementary food and education of mother about complementary food would significantly improve the nutritional status of the children in the intervention group compared to control. Meta-analyses were generated for change in weight and height by two methods. In the first instance, we pooled the results to get weighted mean difference (WMD) which helps to pool studies with different units of measurement and that of different duration. A second meta-analysis was conducted to get a pooled estimate in terms of actual increase in weight (kg) and length (cm) in relation to the intervention, for input into the LiST model. After screening 3795 titles, we selected 17 studies for inclusion in the review. The included studies evaluated the impact of provision of complementary foods (± nutritional counseling) and of nutritional counseling alone. Both these interventions were found to result in a significant increase in weight [WMD 0.34 SD, 95% CI 0.11 - 0.56 and 0.30 SD, 95 % CI 0.05-0.54 respectively) and linear growth [WMD 0.26 SD, 95 % CI 0.08-0.43 and 0.21 SD, 95 % CI 0.01-0.41 respectively]. Pooled results for actual increase in weight in kilograms and length in centimeters showed that provision of appropriate complementary foods (± nutritional counseling) resulted in an extra gain of 0.25 kg (± 0.18) in weight and 0.54 cm (± 0.38) in height in children aged 6-24 months. The overall quality grades for these estimates were that of 'moderate' level. These estimates have been recommended for inclusion in the Lives Saved Tool (LiST) model. Education of mother about complementary feeding led to an extra weight gain of 0.30 kg (± 0.26) and a gain of 0.49 cm (± 0.50) in height in the intervention group compared to control. These estimates had been recommended for inclusion in the LiST model with an overall quality grade assessment of 'moderate' level. Provision of appropriate complementary food, with or without nutritional education, and maternal nutritional counseling alone lead to significant increase in weight and height in children 6-24 months of age. These interventions can significantly reduce the risk of stunting in developing countries and are recommended for inclusion in the LiST tool.
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Given the recognized benefits of breastfeeding for the health of the mother and infants, the World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months of life. However, the prevalence of EBF is low globally in many of the developing and developed countries around the world. There is much interest in the effectiveness of breastfeeding promotion interventions on breastfeeding rates in early infancy. A systematic literature was conducted to identify all studies that evaluated the impact of breastfeeding promotional strategies on any breastfeeding and EBF rates at 4-6 weeks and at 6 months. Data were abstracted into a standard excel sheet by two authors. Meta-analyses were performed with different sub-group analyses. The overall evidence were graded according to the Child Health Epidemiology Reference Group (CHERG) rules using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria and recommendations made from developing country studies for inclusion into the Live Saved Tool (LiST) model. After reviewing 968 abstracts, 268 studies were selected for potential inclusion, of which 53 randomized and quasi-randomized controlled trials were selected for full abstraction. Thirty two studies gave the outcome of EBF at 4-6 weeks postpartum. There was a statistically significant 43% increase in this outcome, with 89% and 20% significant increases in developing and developed countries respectively. Fifteen studies reported EBF outcomes at 6 months. There was an overall 137% increase, with a significant 6 times increase in EBF in developing countries, compared to 1.3 folds increase in developed country studies. Further sub-group analyses proved that prenatal counseling had a significant impact on breastfeeding outcomes at 4-6 weeks, while both prenatal and postnatal counseling were important for EBF at 6 months. Breastfeeding promotion interventions increased exclusive and any breastfeeding rates at 4-6 weeks and at 6 months. A relatively greater impact of these interventions was seen in developing countries with 1.89 and 6 folds increase in EBF rates at 4-6 weeks and at 6 months respectively.
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To investigate whether children in households involved in a participatory agriculture and nutrition intervention had improved growth compared to children in matched comparable households and whether the level of involvement and length of time in the project had an effect on child growth. A prospective quasi-experimental study comparing baseline and follow-up data in 'intervention' villages with matched subjects in 'comparison' villages. Mixed model analyses were conducted on standardized child growth scores (weight- and height-for-age Z-scores), controlling for child age and testing for effects of length of time and intensity of village involvement in the intervention. A participatory agriculture and nutrition project (the Soils, Food and Healthy Communities (SFHC) project) was initiated by Ekwendeni Hospital aimed at improving child nutritional status with smallholder farmers in a rural area in northern Malawi. Agricultural interventions involved intercropping legumes and visits from farmer researchers, while nutrition education involved home visits and group meetings. Participants in intervention villages were self-selected, and control participants were matched by age and household food security status of the child. Over a 6-year period, nine surveys were conducted, taking 3838 height and weight measures of children under the age of 3 years. There was an improvement over initial conditions of up to 0·6 in weight-for-age Z-score (WAZ; from -0·4 (sd 0·5) to 0·3 (sd 0·4)) for children in the longest involved villages, and an improvement over initial conditions of 0·8 in WAZ for children in the most intensely involved villages (from -0·6 (sd 0·4) to 0·2 (sd 0·4)). Long-term efforts to improve child nutrition through participatory agricultural interventions had a significant effect on child growth.
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This controlled clinical trial, conducted in southern Brazil, assessed the impact of paternal inclusion in a breastfeeding education program carried out in a maternity hospital. Rates of breastfeeding in the first 6 months of babies' lives were measured in 586 families: 201 in the control group, 192 in the group with only mothers exposed to the intervention, and 193 in the group with mothers and fathers exposed to the intervention. Paternal inclusion significantly increased the rates of exclusive breastfeeding but not the rates of any breastfeeding. Intervention with fathers with less than 8 years of schooling resulted in a decrease in the rate of breastfeeding when compared with the intervention with mothers only. The likelihood of success might have been greater if the cultural and behavioral complexities associated with this practice had received more attention.
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Earlier research on health promotion has emphasized behavior change strategies rather than environmentally focused interventions. The advantages of integrating lifestyle modification, injury control, and environmental enhancement strategies of health promotion are substantial. The author offers a social ecological analysis of health promotive environments, emphasizing the transactions between individual or collective behavior and the health resources and constraints that exist in specific environmental settings. Directions for future research on the creation and maintenance of health promotive environments also are examined.
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Prolonged breastfeeding in developing countries is routinely recommended as a valuable and cost-effective public health measure to promote early childhood growth. However, the effects of breastfeeding beyond 12 months are unclear, with some studies showing positive, and some showing negative effects. The role of complementary foods for children 1-3 years has been less studied. We examined feeding behaviour and illness data in relation to anthropometric status among 154 rural western Kenyan children, aged 12-36 months. There was little difference in anthropometric status between partially breastfed and fully weaned children. Rather, dietary diversity (number of different foods consumed) was strongly and consistently related to anthropometric status in this age group. In addition, early complementation with starchy gruels was associated with stunting. Public health efforts which focus only on prolonged breastfeeding (>12 months) in developing countries will not ensure adequate early childhood growth. Important complementary feeding recommendations that promote diet diversity, through the inclusion of a variety of foods in the diets of children in the 1-3 year age group, are needed.
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To assess the impact that a mother-to-mother support program operated by La Leche League Guatemala had on early initiation of breast-feeding and on exclusive breast-feeding in peri-urban Guatemala City, Guatemala. A population census was conducted to identify all mothers of infants < 6 months of age, and the mothers were then surveyed on their breast-feeding practices, in two program communities and two control communities. Data collection for this follow-up census and survey was carried out between November 2000 and January 2001, one year after a baseline census and survey had been conducted. At follow-up, 31% of mothers in the program communities indicated that counselors had advised them about breast-feeding, 21% said they had received a home visit, and 16% reported attending a support group. Community wide rates of early initiation of breast-feeding were significantly higher in program areas than in the control communities, at both baseline and follow-up. However, the change over time in early initiation in program communities was not significantly different from the change in control communities. Community wide rates of exclusive breast-feeding were similar in program and control sites and did not change significantly from baseline to follow-up. However, of the mothers in the program communities who both received home visits and attended support groups, 45% of them exclusively breast-fed, compared to 14% of women in program communities who did not participate in those two activities. In addition, women who were exposed to mother-to-mother support activities during the year following the baseline census and survey were more likely than mothers exposed before that period to exclusively breast-feed. This suggests that the program interventions became more effective over time. This study does not provide evidence of population impact of La Leche League's intervention after one year of implementation. In peri-urban Guatemala, long-term community-based interventions, in partnership with existing health care systems, may be needed to improve community wide exclusive breast-feeding rates.
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To review the impact of agriculture interventions on nutritional status in participating households, and to analyse the characteristics of interventions that improved nutrition outcomes. We identified and reviewed reports describing 30 agriculture interventions that measured impact on nutritional status. The interventions reviewed included home gardening, livestock, mixed garden and livestock, cash cropping, and irrigation. We examined the reports for the scientific quality of the research design and treatment of the data. We also assessed whether the projects invested in five types of 'capital' (physical, natural, financial, human and social) as defined in the Sustainable Livelihoods Framework, a conceptual map of major factors that affect people's livelihoods. Most agriculture interventions increased food production, but did not necessarily improve nutrition or health within participating households. Nutrition was improved in 11 of 13 home gardening interventions, and in 11 of 17 other types of intervention. Of the 19 interventions that had a positive effect on nutrition, 14 of them invested in four or five types of capital in addition to the agriculture intervention. Of the nine interventions that had a negative or no effect on nutrition, only one invested in four or five types of capital. Those agriculture interventions that invested broadly in different types of capital were more likely to improve nutrition outcomes. Those projects which invested in human capital (especially nutrition education and consideration of gender issues), and other types of capital, had a greater likelihood of effecting positive nutritional change, but such investment is neither sufficient nor always necessary to effect change.
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The health and nutritional status of children aged 5 and under was assessed in three villages in Siaya District of western Kenya. A cross-sectional survey was conducted among 121 adults and 175 children during July 2002. Primary caretakers were interviewed during home visits to assess agricultural and sanitation resources, child feeding practices, and the nutritional status of their children aged 5 years and under. Through anthropometry, the prevalence of underweight, stunting and wasting were determined: 30 per cent were underweight, 47 per cent were stunted, and 7 per cent were wasted. Predictors of undernutrition were analysed using logistic regression controlling for age, sex, and SES, and four major findings emerged. First, children in their second year of life were more likely to be underweight and stunted. Second, children who were introduced to foods early had an increased risk of being underweight. Third, up-to-date vaccinations were protective against stunting, while reports of having upper respiratory infections or other illness in the past month predicted underweight. Finally, living with non-biological parents significantly increased risk of stunting. Emphasis should be placed on current immunization, prolonging exclusive breastfeeding, and improving access to nutrient-rich foods among adopted children and their families via community-based nutrition interventions.
Article
Rationale: Food insecurity during pregnancy is concerning given the increased nutritional needs of the mother for proper fetal development. However, research is lacking within the South African context to investigate the association of economic and psychosocial factors and food insecurity among pregnant women, using comprehensive, conceptually driven models. Objective: This study applies the Network-Individual-Resource (NIR) Model to investigate individual, intimate dyadic, and family level predictors of perceived household food insecurity for pregnant women. Methods: 826 pregnant women enrolled in the Drakenstein Child Health Study (DCHS), a birth cohort in two communities in a peri-urban area of South Africa. Hierarchical logistic regressions were used to investigate the impact of household/family, intimate dyads, and individual tangible and mental resources on perceived household food insecurity during the critical period of pregnancy. Perceived household food insecurity was assessed through an adapted version of the USDA Household Food Security Scale - Short Form. Results: Among 826 pregnant women in South Africa, individual-level tangible resources (e.g. income, social assistance, HIV status) and mental resources (e. g. depression, childhood trauma) predicted perceived household food insecurity and these predictors differed by community. Intimate dyadic and family level resources did not predict household food insecurity. Conclusions: Our findings of the economic and psychosocial predictors of perceived household food insecurity among pregnant women in South Africa, mirror findings in general populations. This study provides support for the extension of the NIR model to perceived household food insecurity, particularly regarding individual-level mental and tangible resources, as well as the impact of community-level factors. Future research should investigate the extent to which resource sharing occurs within networks.
Article
Food insecurity, the state of being without reliable access to a sufficient quantity of safe, nutritious food, is a persistent problem in rural Ethiopia. However, little qualitative research has explored how food insecurity affects children over time, from their point of view. What are the effects of economic ‘shocks’ such as illness, death, loss of livestock, drought and inflation on availability of food, and children's well-being? To what extent do social protection schemes (in this case, the Productive Safety Net Programme) mitigate the long-term effects of food insecurity for children? The paper uses a life-course approach, drawing on analysis of four rounds of qualitative longitudinal research conducted in 2007, 2008, 2011 and 2014, with eight case study children, as part of Young Lives, an ongoing cohort study. Children's descriptions of the importance of food and a varied diet (dietary diversity) in everyday life were expressed in a range of qualitative methods, including interviews, group discussions and creative methods. The paper suggests that while the overall picture of food security in Ethiopia has improved in the past decade, for the poorest rural families, food insecurity remains a major factor influencing decisions about a range of matters – children's time allocation, whether to continue in school, whether to migrate for work, and whether they marry. The paper argues that experiences of food insecurity need to be understood holistically, in relation to other aspects of children's lives, at differing stages of the life-course during childhood. The paper concludes that nutritional support beyond early childhood needs to be a focus of policy and programming.
Article
Significance: Maternal factors such as autonomy are associated with child feeding practices and nutritional status, with varying degrees depending on the definition of maternal-level constructs and context. This study describes the events and processes that constrain maternal capabilities-intrapersonal factors that shape mother's abilities to leverage resources to provide care to children-as they relate to nutrition and hygiene practices. We report community beliefs and understandings about which capabilities have meaning for child nutrition and hygiene, and develop a conceptual framework to describe how these capabilities are formed and describe implications for future nutrition programs in East Africa and similar settings.
Article
Rationale: Food insecurity has emerged as an important, and potentially modifiable, risk factor for depression. Few studies have brought longitudinal data to bear on investigating this association in sub-Saharan Africa. Objective: To estimate the association between food insufficiency and depression symptom severity, and to determine the extent to which any observed associations were modified by social support. Methods and results: We conducted a secondary analysis of population-based, longitudinal data collected from 1238 pregnant women during a three-year cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 months, 18 months, and 36 months (85% retention). A validated, single-item food insufficiency measure inquired about the number of days of hunger in the past week. Depression symptom severity was measured using the Xhosa version of the 10-item Edinburgh Postnatal Depression Scale. In multivariable regression models with cluster-correlated robust estimates of variance, lagged food insufficiency had a strong and statistically significant association with depression symptom severity (β = 0.70; 95% CI, 0.46-0.94), suggesting a 6.5% relative difference in depression symptom severity per day of hunger. In stratified analyses, food insufficiency had a statistically significant association with depression only among women with low levels of instrumental support. Using quantile regression, we found that the adverse impacts of food insufficiency were experienced to a greater degree by women in the upper end of the conditional distribution of depression symptom severity. Estimates from fixed-effects regression models and fixed-effects quantile regression models, accounting for unobserved confounding by time-invariant characteristics, were similar. Conclusions: Food insufficiency was associated with depression symptom severity, particularly for women in the upper end of the conditional depression distribution. Instrumental social support buffered women against the adverse impacts of food insufficiency.
Article
Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon. We conducted a quasi-experimental study evaluating the impact of the Microclinic social network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in ten bi-weekly discussion sessions covering topics ranging from HIV biology to group support, as well as group HIV status disclosure. Nevirapine concentrations in hair were measured pre-and-post study. 113 (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-months of follow-up, intervention community participants experienced one-half the rate of ≥90-day clinic absence as those in control communities (adjusted hazard ratio 0.48, 95%CI 0.25-0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% CI -2.7 to 16.1). The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity and mortality, and for broader community empowerment and engagement in healthcare.
Article
The prevalence of obesity has increased substantially over the past 30 years. We performed a quantitative analysis of the nature and extent of the person-to-person spread of obesity as a possible factor contributing to the obesity epidemic. We evaluated a densely interconnected social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study. The body-mass index was available for all subjects. We used longitudinal statistical models to examine whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors. Discernible clusters of obese persons (body-mass index [the weight in kilograms divided by the square of the height in meters], > or =30) were present in the network at all time points, and the clusters extended to three degrees of separation. These clusters did not appear to be solely attributable to the selective formation of social ties among obese persons. A person's chances of becoming obese increased by 57% (95% confidence interval [CI], 6 to 123) if he or she had a friend who became obese in a given interval. Among pairs of adult siblings, if one sibling became obese, the chance that the other would become obese increased by 40% (95% CI, 21 to 60). If one spouse became obese, the likelihood that the other spouse would become obese increased by 37% (95% CI, 7 to 73). These effects were not seen among neighbors in the immediate geographic location. Persons of the same sex had relatively greater influence on each other than those of the opposite sex. The spread of smoking cessation did not account for the spread of obesity in the network. Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions.
Article
Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?. By - Prof Zulfiqar A Bhutta PhD, Jai K Das MBA, Arjumand Rizvi MSc, Michelle F Gaff...
Article
Children need to be protected in intergenerational networks, with parents who have positive mood, resources to feed their children, and skills to promote early childhood development (ECD). Globally, more than 200 million children are raised annually without these resources. This article reviews the potential contributions of increasing coverage and penetration of services for these children, challenges to achieving penetration of services in high-risk families, opportunities created by bundling multiple services within one provider, potential leveraging of paraprofessionals to deliver care, and mobilizing communities to support children in households at high risk for negative outcomes. We end with a number of suggestions for how to ensure the equitable scale-up of integrated ECD and nutrition services that take into account current global priorities, as well as coverage and penetration of services.
Article
Acceleration of progress in nutrition will require eff ective, large-scale nutrition-sensitive programmes that address key underlying determinants of nutrition and enhance the coverage and eff ectiveness of nutrition-specifi c interventions. We reviewed evidence of nutritional eff ects of programmes in four sectors—agriculture, social safety nets, early child development, and schooling. The need for investments to boost agricultural production, keep prices low, and increase incomes is undisputable; targeted agricultural programmes can complement these investments by supporting livelihoods, enhancing access to diverse diets in poor populations, and fostering women’s empowerment. However, evidence of the nutritional eff ect of agricultural programmes is inconclusive—except for vitamin A from biofortifi cation of orange sweet potatoes—largely because of poor quality evaluations. Social safety nets currently provide cash or food transfers to a billion poor people and victims of shocks (eg, natural disasters). Individual studies show some eff ects on younger children exposed for longer durations, but weaknesses in nutrition goals and actions, and poor service quality probably explain the scarcity of overall nutritional benefi ts. Combined early child development and nutrition interventions show promising additive or synergistic eff ects on child development—and in some cases nutrition—and could lead to substantial gains in cost, effi ciency, and eff ectiveness, but these programmes have yet to be tested at scale. Parental schooling is strongly associated with child nutrition, and the eff ectiveness of emerging school nutrition education programmes needs to be tested. Many of the programmes reviewed were not originally designed to improve nutrition yet have great potential to do so. Ways to enhance programme nutrition-sensitivity include: improve targeting; use conditions to stimulate participation; strengthen nutrition goals and actions; and optimise women’s nutrition, time, physical and mental health, and empowerment. Nutrition-sensitive programmes can help scale up nutrition-specifi c interventions and create a stimulating environment in which young children can grow and develop to their full potential.
Article
Researchers increasingly include multicultural respondents in qualitative research studies. The grounded theory method, a currently popular qualitative methodology, seeks to interpret data for theory development. However, analysis of respondents from a culture(s) significantly different from the researcher's culture requires special attention to methodological issues. Requirements for conducting a grounded theory analysis with respondents from varying cultural orientations include personal or professional experience in the respondent's culture, professional literature of the respondent's culture around the phenomenon of interest, data analysis conducted in the language of the respondents, and a constant comparison of emerging concepts from the cultural perspective of the respondents. Only by attending to the cultures of the respondents and of the researchers can the social sciences create sufficiently rich inductively derived grounded theory.
Article
The objective of this review is to systematically examine and summarise the effects of agricultural interventions to increase household food production on the nutrition and health outcomes of women and young children and provide recommendations for future research and programming. Data from all studies meeting inclusion/exclusion criteria were abstracted into a standardised form. The quality of the evidence was assessed and graded using a modified version of the Child Health Epidemiology Reference Group adaptation of the Grading of Recommendations, Assessment, Development and Evaluation technique. Thirty-six articles, representing 27 unique projects were identified. Of these 32 and 17 reported on the health and nutrition outcomes of children and women, respectively. Although studies were too heterogeneous to conduct meta-analysis, agricultural strategies consistently reported significantly improved diet patterns and vitamin A intakes for both women and children. Although some individual studies reported significant reductions in child malnutrition, summary estimates for effects on stunting [relative risk (RR) 0.93 [95% confidence interval (CI) 0.84, 1.04]], underweight (RR 0.80 [95% CI 0.60, 1.07]) and wasting (RR 0.91 [95% CI 0.60, 1.38]) were not significant. Findings for an effect on vitamin A status, anaemia and morbidity were inconsistent. Overall the evidence base for the potential of agricultural strategies to improve the nutrition and health of women and young children is largely grounded in a limited number of highly heterogeneous, quasi-experimental studies, most of which have significant methodological limitations. While household food production strategies hold promise for improving the nutrition of women and children, the evidence base would be strengthened by additional research that is methodologically robust and adequately powered for biological and dietary indicators of nutrition.
Article
People are interconnected, and so their health is interconnected. In recognition of this social fact, there has been growing conceptual and empirical attention over the past decade to the impact of social networks on health. This article reviews prominent findings from this literature. After drawing a distinction between social network studies and social support studies, we explore current research on dyadic and supradyadic network influences on health, highlighting findings from both egocen-tric and sociocentric analyses. We then discuss the policy implications of this body of work, as well as future research directions. We conclude that the existence of social networks means that people's health is inter-dependent and that health and health care can transcend the individual in ways that patients, doctors, policy makers, and researchers should care about.
Article
This overview of recent research on health behaviour change in developing countries shows progress as well as pitfalls. In order to provide guidance to health and social scientists seeking to change common practices that contribute to illness and death, there needs to be a common approach to developing interventions and evaluating their outcomes. Strategies forming the basis of interventions and programs to change behaviour need to focus on three sources: theories of behaviour change, evidence for the success and failure of past attempts, and an in-depth understanding of one's audience. Common pitfalls are a lack of attention to the wisdom of theories that address strategies of change at the individual, interpersonal, and community levels. Instead, programs are often developed solely from a logic model, formative qualitative research, or a case-control study of determinants. These are relevant, but limited in scope. Also limited is the focus solely on one's specific behaviour; regardless of whether the practice concerns feeding children or seeking skilled birth attendants or using a latrine, commonalities among behaviours allow generalizability. What we aim for is a set of guidelines for best practices in interventions and programs, as well as a metric to assess whether the program includes these practices. Some fields have approached closer to this goal than others. This special issue of behaviour change interventions in developing countries adds to our understanding of where we are now and what we need to do to realize more gains in the future.
Article
Lake Victoria supports Africa’s largest inland fishery, and its most valuable product is the Nile perch, much of which is exported. This has given rise to arguments claiming a direct linear relationship between perch exports and disturbingly high rates of malnutrition along the lake’s shores. In this paper, we argue that this argument is seriously flawed for it is unable to explain how it is that the income from the Nile perch fishery fails to translate into a well-fed riparian population. We draw on field work carried out in 2001 that (a) set out to establish exactly how much malnutrition there was on the lake’s shores; and (b) sought to identify what happened to the income the fishery generates. We argue that because men control much of the fishery, and women are held responsible for the upkeep of their families, little of this income makes its way back into the households of the region, giving rise to the levels of malnutrition we observed.
Article
This paper explores the dynamics between poverty and exclusion; neighbourhood, and health and well being by considering the role of social networks and social capital in the social processes involved. It is based on qualitative research taking two deprived areas as exemplary case studies, and involving depth interviews with residents. Neighbourhood influences on networks and social capital were explored, network typologies developed reflecting structural and cultural aspects of individual's networks, and pathways implicated in health effects considered. The complexity of social capital is addressed. The role of three factors in influencing social networks and social capital are demonstrated: neighbourhood characteristics and perceptions; poverty and social exclusion, and social consciousness. Perceptions of inequality could be a source of social capital as well as demoralisation. Different network structures- dense and weak, homogeneous and heterogeneous- were involved in the creation of social capital and had implications for well being. Coping, enjoyment of life and hope are identified as benefits. Although participation in organisations was confirmed as beneficial, it is suggested that today's heterogeneous neighbourhoods also require regenerated local work opportunities to develop bridging ties necessary for the genesis of inclusive social capital and better health. Despite the capacity of social capital to buffer its harsher effects, the concept is not wholly adequate for explaining the deleterious effects of poverty on health and well being.
Article
A cross-sectional study was carried out among 280 children (12-23 months), Mwingi district, Kenya. Complementary foods were introduced at age 2.5 ± 1.7 months and the mean duration of breastfeeding was 10.5 ± 4.1 months. An unfortified maize porridge was the main complementary food. At least 60% of the children in all the dietary diversity terciles consumed starchy staples and oils in the preceding 24 hr. The mean dietary diversity score was 4.9 ± 1.3 and 4.3 ± 1.0 out of a possible score of 14 and 8 as suggested by FAO, respectively. Dietary diversity was limited in animal products. Deficits in dietary energy, iron and zinc were found due to early introduction of complementary foods and low consumption of food rich in iron. Establishing local solutions to increase dietary diversity and promote use of foods rich in iron and proteins to improve available complementary diets are needed.
Article
Lake Victoria is the world’s second largest freshwater body and home to one of the most dramatic speciation of indigenous cichlids in the world. Bordered by Kenya, Tanzania and Uganda in East Africa, the Lake Victoria Basin (LVB) provides food, water and livelihoods for over 30 million people around its shores. The Colonial era introduction of the invasive Nile perch (Lates niloticus) the 1950’s, combined with the introduction of industrialized fish processing in the 1980’s, rapidly altered socio-ecological systems throughout the LVB. The introduction and commercial harvesting of the Nile perch, subsequent human population growth, and the looming problems of climate change continue to compromise the health of this socio-ecological system. While the Nile perch trade provides much needed foreign currency to these three exporting nations, the increased fishing pressure on wild stocks, driven by global demand and the subsequent influx of industrial fishing technology, compromises the long term sustainability of wild fish populations, food security and sovereignty, the fishing way of life, and fishing in local places around the lake. The following thesis applies a global commodity chain framework to the case of the export-oriented Nile perch from the Kenyan island of Mfangano comparing 1988 and 2007 European export data. Unless otherwise noted all price and empirical data are based on interviews, market surveys, and participant observation conducted by the author in Kenya in June, July, and August of 2007. In 2007, prices paid to local fishermen and agents represent 23% of the total value from the fishery, prices paid to processors represent 32% of the value, and 45% of the value accrues to international seafood wholesalers and retailers. I also argue that efforts to improve ecological and human health and wellbeing around the basin have failed largely because managers, scholars, and development professionals have overlooked the widespread ecological and domestic violence committed by the Nile perch and Nile perch trade. Through the commodity chain and discussion of resource violence in the LVB I pose critical questions about the value of the fishery to various actors in the global commodity chain. Results from the commodity chain analysis are then used to critically assess ongoing and proposed aquaculture development, sustainability certification for the Nile perch fishery, the establishment of protected areas in the lake. Master of Science Natural Resources and Environment University of Michigan http://deepblue.lib.umich.edu/bitstream/2027.42/58200/1/JLJ Thesis 4-14.doc
Article
A variety of nutrition education interventions and social marketing initiatives are being used by the Food Stamp Program to improve food resource management, food safety, dietary quality, and food security for low-income households. The Social-Ecological Model is proposed as a theory-based framework to characterize the nature and results of interventions conducted through large public/private partnerships with the Food Stamp Program. In particular, this article suggests indicators and measures that lend themselves to the pooling of data across counties and states, with special emphasis on systems, environment, and public policy change within organizations at the community and state levels.
Article
To investigate whether supporting fathers to recognize the relevance of their role in the success of breastfeeding and teaching them how to prevent and to manage the most common lactation problems would result in more women breastfeeding. A controlled trial, in which the participating fathers were allocated in 2-month blocks to a child care training session, was conducted of 280 mothers considering breastfeeding and their 280 partners at a university obstetric department in Naples, Italy. Support and advice about breastfeeding was provided to all of the mothers. Among the fathers of the intervention group, the training session included the management of breastfeeding; among those of the control group, it did not. Primary outcome was the prevalence of full breastfeeding at 6 months. Secondary outcomes were the proportion of women who perceived their milk to be insufficient, who stopped breastfeeding because of problems, and who reported to have received help in breastfeeding management by their partners. The prevalence of full breastfeeding at 6 months was 25% (35 of 140) in the intervention group and 15% (21 of 140) in the control group and that of any breastfeeding at 12 months was 19% (27) and 11% (16), respectively. Perceived milk insufficiency was significantly more frequent among the mothers of the control group (38 [27%] of 140 vs 12 [8.6%] of 140), as well as breastfeeding interruption because of problems with lactation (25 [18%] of 140 vs 6 [4%] of 140). Moreover, significantly more women in the intervention group reported receiving support and relevant help with infant feeding management from their partners (128 [91%] of 140 vs 48 [34%] of 140). Among the women who had reported difficulties with lactation in the intervention and control groups (96 [69%] and 89 [64%], respectively), the prevalence of full breastfeeding at 6 months was 24% and 4.5%, respectively. Teaching fathers how to prevent and to manage the most common lactation difficulties is associated with higher rates of full breastfeeding at 6 months.
Article
This paper describes an innovative public health nursing strategy, village-based fathers clubs, to improve child and family health in rural Haiti. It discusses related nursing implications in Haiti and other parts of the world. Relevant current literature was reviewed and evaluated with respect to child health in Haiti and the development of the fathers clubs. Program participants and organizers were consulted. The fathers clubs in remote areas of Jeremie Haiti, participants and program directors, provided input for this description. Public health practitioners continually face grave challenges when addressing the health care needs in less developed countries. One such case is Haiti, where crushing poverty, poor infrastructure, a failing economy, natural disasters, and chaotic sociopolitical conditions compound these challenges. Public health practitioners, including nurses, must seek creative, culturally-appropriate, low technologic approaches to improve the health of the children and families in the remote villages of Haiti. The institution and support of village fathers clubs is one approach that has been ongoing since 1994. Fathers meet together on a regular basis for health education, support, and community building activities. The curriculum is health-based and facilitated by nurses, with participation by young and old men alike. Participants and organizers believe that family and child health is improved as a result of the groups.